Diary from a Week in Practice



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Am Fam Physician. 1999 Oct 15;60(6):1864-1865.

Monday

When teaching students or residents in our practice, JRH always takes some time to highlight some of the joys of group family practice for them. Today offered an example of one of the aspects that JRH likes best: camaraderie. JRH, JTL and CAG were gathered around the coffee machine when JTL began to unburden himself about a case from the previous evening. Clearly JTL was still emotionally involved in the case, even if the medical aspects were under control. After five minutes of continuing details, CAG was heard to remark, “John, just land the plane.” JTL paused, came up for a breath and wrapped up the presentation. We all had a good laugh and have now incorporated this directive into our favorite phrase list, to be pulled out whenever the situation dictates.

Tuesday

WLL remembers an old wives' tale from his first few years in practice in the Great Smoky Mountains: “If you're having trouble falling asleep, try warming your feet with a hot water bottle and wear socks and mittens.” A new study shows that warm feet and hands may, indeed, help induce sleep quickly. Researchers have discovered that the degree of dilation of blood vessels in the hands and feet is one of the best predictors of the rapid onset of sleep (Nature 1999;401: 36–7). In fact, a person's hands and feet should be considerably warmer than the ambient temperature of the bedroom. When a person is preparing for sleep, the body's temperature regulation system normally redistributes heat from its core to its extremities when the body is in a prone position. This phenomenon is also closely associated with the release of hormones, such as melatonin that regulate sleepiness. When heat is lost at the extremities, falling asleep may be more difficult. The study findings showed that warm hands and feet are the best predictors of the body's readiness for sleep. The researchers speculated that an intervention as simple as wearing socks or placing a hot water bottle at the feet or wearing mittens on the hands could help induce sleep more quickly, especially in persons with poor vasodilation. The researchers also hypothesized that persons with poor circulation, such as the elderly, might benefit from this approach.

Wednesday

Being a young doctor who looks even younger than he actually is, CAG hears a lot of comments about his age from patients and medical staff. It is not uncommon for an older patient to put an arm around him and proudly proclaim to one of our nurses, “I'm training him to be my doctor.” Today, CAG was visiting a patient in labor at the hospital. CAG was dressed casually and relaxed in a rocking chair next to the patient to review her plans and expectations. During the discussion, the patient's mother arrived from out of town and was obviously anxious and concerned about her daughter. They talked for a short time, and then the woman noticed CAG. “Who's your little friend?” she asked. “Mom—that's the doctor!” was the reply. CAG was unsure whether the look on the mother's face was one of embarrassment or shock. After a (thankfully) smooth delivery, she seemed relieved and was quite gracious. Her only question to the youthful-appearing CAG was, “How many circumcisions have you done?”

Thursday

Although usually careful to avoid the use of acronyms in discussions with patients, JTL found himself reviewing the extensive master problem list of an elderly new patient who presented to him today. Along with the patient was his daughter. “Let's see,” JTL commenced, “CHF, COPD, BPH . . .” He was interrupted by the patient's daughter, who said, “I'm not sure what all you are talking about, but I can tell you right now what my father's biggest problem is—TMP.” Not recalling that particular acronym, JTL asked for an explanation. “Too many pills,” replied the daughter emphatically. JTL chuckled and reassured the daughter that, in fact, he derived a great deal of pleasure from taking patients off of any prescription medications that they do not need. Henceforth, JTL stated, at least one problem would not appear on this master problem list—TMP.

Friday

After reading a previous diary entry (Am Fam Physician 1999;59(5):1157–9) about an obese patient of CAG's who went to the local grain and feed store to be weighed, Dr. Kathy Miller of Lexington, Ky., sent a helpful article that suggested hanging a small weight on the beam end of the scale so that heavier patients still register on the scale. The difference caused by the small weight can be calculated by someone weighing with and without the extra weight, and the obese patient's weight can then be calculated. Although unable to hang objects from the end of his scale, CAG was able to obtain the same effect by placing a stack of nickels on the end of the lower bar of the scale. Today, one of CAG's obese patients proudly proclaimed, “I appreciate your thoughtfulness, but your nickels weren't necessary.” Although the patient started out weighing more than 400 lb, today he weighed in at 345 lb, below our scale's 350-lb maximum. The patient said he planned to tell his wife that his new goal was to “avoid the nickels.”

Saturday/Sunday

Family physicians have the privilege of taking care of families, and from personal and professional experience, most family physicians quickly learn that the job of a mother is one of the most difficult ever designed, for mothers who have additional work outside the home and mothers who stay at home. For most mothers, the job of running a household is no different than a chief executive officer's job of running a business. WLL calls the mothers in his practice the “CEO” of the home, and these CEOs know all too well that keeping a family on track is anything but glamorous. It is hard work. It requires a strong stomach, forgiving heart and calluses on the knees. As a family advisor, WLL often recommends practical resources for the mothers in his practice to help them in their day-to-day duties. One of his favorites is a book written by Kathy Peel, an experienced mom (Peel K. The family manager. Dallas: Word Publishing, 1996). WLL and his wife, Barb, have used many of the book's thousands of recommendations in their home, and WLL recommends it to the mothers who visit his practice.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Chad A. Griffin, M.D., and John T. Littell, M.D., four family physicians in private practice in Kissimmee, Fla.


Copyright © 1999 by the American Academy of Family Physicians.
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